Putting psychological interventions first in primary health care

World Psychiatry 22:3 October 2023 pharmacotherapy, psychotherapy, or support groups). The par­ ents may not agree on the need for medications or, if they do, they may not agree on what type or dosage is needed. They may need guidance in advocating for the child within the school system. Siblings may be confused as to their role in helping their ill broth­ er or sister (or, at minimum, how not to trigger symptoms further). A different set of questions may haunt young affected people during this period. These issues surround how the illness will im­ pact their peer and school relationships or activities, or even how their identity has been changed by the illness. They may express considerable resentment toward their parents for seemingly over­ reacting to minor symptoms or for insisting on a regimented life­ style. These issues can become intertwined with the young per­ sons’ struggle for autonomy. Psychiatric treatment may come to symbolize the last bastion of their parents’ control over them, with the psychiatrist seen as an agent of the parents. A key component of psychoeducation is the relapse prevention plan. The patient and the parents make a list of early warning signs of episodes and past stressors – major or minor – that appear to have triggered those episodes (e.g., the start of a new school year). Then, clinicians coach the family to make a list of potential coping strategies (e.g., try to regulate sleep and wake times) and poten­ tial obstacles to their implementation (e.g., foregoing late­ night parties). The plan is modified over time as more data are collected on warning signs, eliciting stressors and effective coping strate­ gies. In later segments of psychoeducation, clinicians attempt to mod ify levels of expressed emotion by guiding families in effective communication and problem­ solving. Clinicians elicit role­ play interchanges between parents and offspring with practice of skills such as active listening, making requests for changes in each oth­ er’s behaviors, and balancing positive and negative feedback. To reduce parent/offspring criticisms (e.g., “I resent the hours you keep”), clinicians can take several steps: a) reframe the criticism as coming out of positive intentions (e.g., “I am worried about you not getting enough sleep and getting ill again”); b) point out that the parent’s manner of delivery is inadvertently alienating the off­ spring; and c) model for the parent how he/she might make a re­ quest for behavior changes (e.g., “I’d appreciate your helping me manage my own anxiety by keeping to a regular bedtime”). These exchanges can be followed by problem­ solving exercises in which family members offer practical input about how to keep consis­ tent nightly routines. Severe family conflict often grows out of parents’ disappoint­ ments over failed expectations of the child. Input from the offspring about what they can or cannot accomplish while still symptom­ atic is essential. The offspring can be coached to make decisions that will enhance their chances of recovery (e.g., avoiding enroll­ ing themselves in too many courses; discontinuing use of canna­ bis or psychostimulants). Recovery can be framed as an objective that must be achieved by the family as a whole, not only by the pa­ tient. Randomized clinical trials indicate that, among youth in the ear­ ly stages of bipolar disorder, a 12­ session, 4­ month protocol of fam­ ily­focused therapy (psychoeducation, communication training and problem­ solving) is associated with shorter depressive epi­ sodes, longer periods of wellness between episodes, and less sui­ cidal ide ation and behavior than briefer forms of education. The broader availability of psychoeducational therapy may do much to reduce the long­ term personal, familial and societal burdens imposed by severe psychiatric disorders.

pharmacotherapy, psychotherapy, or support groups).The par ents may not agree on the need for medications or, if they do, they may not agree on what type or dosage is needed.They may need guidance in advocating for the child within the school system.Siblings may be confused as to their role in helping their ill broth er or sister (or, at minimum, how not to trigger symptoms further).
A different set of questions may haunt young affected people during this period.These issues surround how the illness will im pact their peer and school relationships or activities, or even how their identity has been changed by the illness.They may express considerable resentment toward their parents for seemingly over reacting to minor symptoms or for insisting on a regimented life style.These issues can become intertwined with the young per sons' struggle for autonomy.Psychiatric treatment may come to symbolize the last bastion of their parents' control over them, with the psychiatrist seen as an agent of the parents.
A key component of psychoeducation is the relapse prevention plan.The patient and the parents make a list of early warning signs of episodes and past stressors -major or minor -that appear to have triggered those episodes (e.g., the start of a new school year).Then, clinicians coach the family to make a list of potential coping strategies (e.g., try to regulate sleep and wake times) and poten tial obstacles to their implementation (e.g., foregoing late night parties).The plan is modified over time as more data are collected on warning signs, eliciting stressors and effective coping strate gies.
In later segments of psychoeducation, clinicians attempt to mod ify levels of expressed emotion by guiding families in effective communication and problem solving.Clinicians elicit role play interchanges between parents and offspring with practice of skills such as active listening, making requests for changes in each oth er's behaviors, and balancing positive and negative feedback.To reduce parent/offspring criticisms (e.g., "I resent the hours you keep"), clinicians can take several steps: a) reframe the criticism as coming out of positive intentions (e.g., "I am worried about you not getting enough sleep and getting ill again"); b) point out that the parent's manner of delivery is inadvertently alienating the off spring; and c) model for the parent how he/she might make a re quest for behavior changes (e.g., "I'd appreciate your helping me manage my own anxiety by keeping to a regular bedtime").These exchanges can be followed by problem solving exercises in which family members offer practical input about how to keep consis tent nightly routines.
Severe family conflict often grows out of parents' disappoint ments over failed expectations of the child.Input from the offspring about what they can or cannot accomplish while still symptom atic is essential.The offspring can be coached to make decisions that will enhance their chances of recovery (e.g., avoiding enroll ing themselves in too many courses; discontinuing use of canna bis or psychostimulants).Recovery can be framed as an objective that must be achieved by the family as a whole, not only by the pa tient.
Randomized clinical trials indicate that, among youth in the ear ly stages of bipolar disorder, a 12 session, 4 month protocol of fam ilyfocused therapy (psychoeducation, communication training and problem solving) is associated with shorter depressive epi sodes, longer periods of wellness between episodes, and less sui cidal ide ation and behavior than briefer forms of education 1,7 .The broader availability of psychoeducational therapy may do much to reduce the long term personal, familial and societal burdens imposed by severe psychiatric disorders.

Putting psychological interventions first in primary health care
Task sharing -in which specialists train, supervise and support non specialist health care providers -is proven to be acceptable, feasible and effective in scaling up mental health care for depres sive and anxiety disorders 1 .In this perspective, we focus on reasons for and barriers to task sharing of psychological interventions in primary health care.We also cover what the World Health Orga nization (WHO) does to address these barriers.
Task sharing in primary health care is vital to increase treat ment coverage for people in need, but it rarely includes providing evi dence based psychological interventions.Yet research shows that cognitive behavioral therapy (CBT), on its own or combined with antidepressants, is the first line treatment for adult depressive dis orders 2 .CBT is also first line treatment for other conditions, includ ing anxiety disorders.Several other psychological therapies -such as interpersonal, problem solving and behavioral activation ther apies -are likely equally effective 3 .
Many evidence based psychological interventions are well suited to task sharing.They can be designed to be safely delivered by supervised non specialists.They can be adjusted to be briefer and less resource intensive than conventional psychotherapy, without being less effective 1 .And they can be adapted for remote or group delivery or provided through guided or unguided self help man uals, websites and applications.WHO's Problem Management Plus, for example, comprises just five weekly sessions, can be deliv ered to individuals or groups, and is suitable for many con texts, types of adversity and types of helpers 4 .
Despite their potential, psychological interventions are rarely provided at scale 5 .Yet scale up is possible.The National Mental Health Programme in Lebanon is showing that implementing a na tionwide self help intervention for depression is feasible, even amid multiple crises 1,6 .
There are many barriers to including psychological interven tions in task sharing: • Lack of political support.Despite the evidence, decision makers in many countries remain unaware of the effectiveness of psy chological interventions and so exclude them from universal health coverage packages of essential services and financial protection schemes.Building on the work of many others, the WHO is addressing a range of these barriers.We recommend psychological interven tions and promote task sharing through our Comprehensive Mental Health Action Plan 2013 2030, our mhGAP programme, our Universal Health Coverage (UHC) compendium and our World Mental Health Report 1 .We develop, test and publish open access diverse psychological interventions that are scalable and suit dif ferent delivery models.And we support training and supervision tools to help assure a competent non specialist workforce through our Ensuring Quality in Psychological Support (EQUIP) initiative 9 .
We are also finalizing a new, operational guide -a Psychological Interventions Implementation Manual -to help service planners and programmers add psychological interventions to their ser vices.Written for managers and others responsible for planning and implementing services, this manual provides practical guid ance on how to plan, prepare and provide psychological interven tions within existing services, such as health, social or education services.
This new WHO manual advises service planners on how to: a) choose and adapt psychological interventions to be relevant for their specific settings; b) decide a setting and system for delivery, including linking to associated services; c) develop a competent workforce by selecting, training, assessing and supervising provid ers; d) identify potential service users, assess their support needs and ensure people get the care they need; and e) use monitoring and evaluation to evaluate and improve the service provided.
The manual marks the latest addition to our toolbox for psy chological interventions.After publication, it will be field tested and refined.
Service planners can now freely access all the resources they need to implement psychological interventions: intervention man uals, tools to support competence, and operational guidance for implementation.The next big step is to get these resources into use.Ultimately, this work is intended to help improve the quality and local availability of evidence based mental health care, so that millions more people with depression and anxiety will be effective ly helped.

•
Resistance to change.Still some psychologists today -in cluding some national psychological associations -are against sharing responsibility for delivering psychological treatments with non specialists.The reality though is that no society, however rich, will ever have enough specialists to offer more than a fraction of the volume of care required to help the large numbers of people who need mental health interventions.•Littlecommercialincentive.Despite their cost effectiveness, there is little commercial incentive to make psychological inter ventions widely available.By comparison, pharmacol ogical interven tions are heavily promoted by pharmaceutical compa nies, which may influence decision makers and medical staff to focus on drug treatments6.• Lack of human resources.Task sharing for psychological inter ventions in primary health care typically means recruiting and retaining additional (non specialist, community based) staff to deliver those interventions.This is needed since medical staff in primary health care typically have heavy workloads and, while they can refer people for psychological interventions, they rarely have time to deliver lengthy therapeutic sessions them selves.• Lack of financial resources.Funding a national workforce of pro viders, trainers and supervisors demands larger mental health budgets than are currently available.This means that more funds must be allocated within health budgets or, importantly, from the state treasury.• Lack of access to relevant tools.Too few proven psychological in tervention manuals for non specialists are freely available (open access) 7 .• Lack of operational guidance.Apart from the Design, Imple men tation, Monitoring and Evaluation (DIME) manuals 8 , there is little international guidance on how to integrate psychologi cal interventions in primary health care.Even if service plan ners want to add those interventions to their services, they may not know what steps, service models and resources they need.